DOCtalk by Dr. Gregg 11/4/13

The Nightmare After Halloween

My youngest son wanted to watch Tim Burton’s oddball Halloween/Christmas animated movie “The Nightmare Before Christmas” on Halloween night. We did. Little did I know it would the harbinger of dreadful things to follow.

I awoke the following day, sipped coffee, caught up on email (again learning that Barrister J. Tongai had $20 million ready to send to me for safekeeping), and readied for what seemed like any other day at the office. I should have heard the ominous music begin to swell on my life’s soundtrack.

When I arrived at the office, everything looked normal enough. The staff’s good morning greeting sounded routine and pleasant. The lights were on and the cichlids were silently swimming in our waiting area aquarium.

However, when I rounded the corner into our main work zone, I stopped dead in my tracks. Everywhere I looked I saw piles of paper! Charts and chart notes, faxes and physical forms, school notes and sticky notes, letters and legal papers – all strewn about in some monstrous organizational pattern which I had long ago forgotten.

I’m not ashamed to say I shrieked, just a little.

My office manager, Maggie, looked up and asked, “You OK?” I silently trembled, minimally shaking my head. “What’s wrong?” she again queried me. Still dumbstruck, I felt myself fall back a half step, almost losing my balance before catching myself by grabbing a counter.

The rest of the staff now noticed and turned to see what was up, still acting as if nothing was amiss. The horrified look on my face must have been evidence enough, for they all said, almost as if scripted and in near harmony, “What’s the matter?”

I shook my head again, quickly, trying to stir some words from my throat. I let out only a small whimper at first, but was able to find my tongue shortly thereafter. “What the hell is going on here?” I asked with more of a plea to my voice than I intended.

“What do you mean,” asked Kim, my salt-of-the-earth nurse.

“Where on God’s green earth did all this paper come from? Where did those charts come from? Why is this place such a chaos of wood pulp?” The questions rolled out in a near singular sentence.

The staff all looked at each other with eyes that bespoke their befuddlement (and possible curiosity about my sanity.) “What do you mean?” questioned Kim yet again. “We thought we had cleared through a lot of the stacks from yesterday. This looks good compared to how it looked an hour ago.”

I could feel my knees begin to buckle. I looked about. All I could see were piles upon piles. There were lab results in piles, consultant notes in piles, radiology readings in piles, patient phone call messages in piles, prescription requests in piles, unsorted faxes in piles, charts upon charts in piles. Piles and piles of paper, everywhere.

Then I noticed: no computers! The desktops were gone. The laptops were gone. The tablets were gone. The high end scanner was gone. The insurance card scanner was gone. The credit card scanner was gone. The patient touchscreen registration portals were gone. No digital anything anywhere my eye could see, save the fax which was busy spewing forth ever more paper.

It took only a moment before the full weight and meaning of this fell upon me like a load of wet cement: I had lost virtually all connectivity! (Except for the fax machine, though it’s paper and ink consumption only served to deepen the impact of the moment.) My lab interface was gone. My immunization registry connection was gone. Our online scheduling was gone. Our secure patient email was gone. Our barcode scanning and supply chain management was gone. Our digital referral capacity was gone. Our website was gone. Our HIE interface was gone. OUR EMR WAS GONE!

“NOOOOO!!!” I screamed in absolute horror. “This can’t be happening! What’s going on here? This is unthinkable! No. No. No…”

Maggie arose and grabbed me by the arm, leading me to a chair. She sat me down and said, “Dr. A., you seem a little more off today than normal. Why don’t you take a minute to sit and maybe take a few deep breaths? You just sit there and we’ll bring you a cup of coffee. Barb, get Dr. A. a coffee,” she directed. “I’ll grab your stack of charts from yesterday so you can finish them up while you compose yourself.”

She reached over and lifted a stack of twenty some charts about a foot and a half tall from the morass of chart piles. As she turned to carry them over to me I jumped from the chair and ran screaming bloody murder toward the door. I didn’t see the PDR sitting on the floor before my foot found it and sent my head into the wall.

When I awoke, I was snuggled in my bed with my smart phone alarm just beginning to buzz.

Rubbing the sleep from my eyes, I made a promise to myself to never, ever again watch The Nightmare Before Christmas, son or no son.

From the trenches…

“I am the shadow on the moon at night. Filling your dreams to the brim with fright.” – Oogie Boogie in The Nightmare Before Christmas

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, an HIT and marketing consultant, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).

From the Consultant’s Corner 11/2/13

Change Management: The Path to EHR Clinician Adoption

Most of us are excited when we see provider order entry rates of 80-90 percent in our health systems. We should be proud of our users; it’s not an easy milestone to reach when transitioning from old systems or paper. Most of us also realize these target numbers are a poor indication of the overall performance and satisfaction of our clinicians. Let’s face it: we aren’t offering alternatives save for some scribes, emergent and transcribed orders, and perhaps we shouldn’t be.

Unhappy clinicians use the EHR because they have to. Happy adopters put the system to work for them, and demand results. They’re asking for the support to be efficient with the system, yet attentive with patients relevant and accessible data; timely, accurate and functional decision support;  the ability to personalize tools and content; feedback mechanisms driving content localization and formulary adaptation reflecting site needs. Where to begin?

We have strategy meetings seeking readmission rate reductions, clinical integration improvement, population health programs, business intelligence platform development and much more. Are we doing all we can to support EHR usability and functional flexibility with a true governance backbone?

Many of us are re-evaluating our approach to satisfaction or just starting down the path of improving adoption of the EHR. I’d suggest focusing on four themes to manage the change, identify resistance and provide the incentive for meaningful adoption.

1. Improve governance alignment. Many of us have too many committees. While that may not change, we can certainly align our leadership and communication. The Physician Advisory Council, P&T committee, Medical Group leaders, Medical Executive Chair, clinical CXOs, and clinician champions should have a shared adoption agenda and prioritization for improving the EHR. Disconnects between these groups lead to stagnant or slow optimization. Is your vision and elevator story for leveraging technology across the care continuum transparent and similar across your executive teams? Including representation on your EHR interdisciplinary leadership team from these groups brings speed and competency to decision making. We must align our agenda (and re-evaluate team membership) to reach our goals. For those large multi-hospital multi-practice sites, invest in and support a local governance structure that mirrors your corporate team. Build strong bridges with your sites. Develop a reputation of responsiveness and alignment.

2. Develop adaptation guidelines. What does standardization, localization, and adaptation mean in your organization? How much control do your practice sites and hospitals have to flex and evolve your clinical content tools? We have resource limitations, though we can be transparent about our aims. Perhaps you have four lab systems and have yet to standardize the ancillary approach. Perhaps evidence shows different patient population-based medication response so certain formulary variation is valid. Perhaps sub-specialty scope of practice demands different EHR design or content. Clinical evidence may drive order set template creation and the EHR note format may be in a standard design, but don’t wait to be asked for the rules of engagement. Educate your users on the rules of change, who to work with on feedback and why it’s for the benefit of all. Do your sites know your adaptation guidelines?

3. Define user segments and training needs. One-size-fits-all training? Yawn! Technology-savvy residents expect the high-powered EHR. Some long-time clinicians fear the computer mouse. Know your audience, customize your training approach and build a segmentation tool to help. Key segments include your usual hospitalists, PCPs, specialists, surgeons, floor nurses and LPNs, though getting granular is important. Work with your department heads to identify potential super-users, resisters, folks needing basic computer training, and more. Segment those who may act as mentors. Segment those needing 1-1 training support. Identify rare admitters. Flag who will need refresher training. Educate your EHR training team on your new powerful knowledge about your clinician population, and put it to work as you develop curriculum, training classes and agendas. Track proficiency and follow up with refresher courses and e-learning.

Enable practice and personalization. These steps are often forgotten. Get your users in an EHR playground before going live, and even before upgrades. Assist their familiarity with the new features, workflows and tools, but make it valuable time spent. Provide support to personalize their toolsets in the production environment before going live. Help them modify their note templates, add orders to preference lists and create personalized order set templates before working with patients. On day 1, they’ll hit the ground running and appreciate that the system can work for them.

4. Strengthen post go-live communication. Some parents compare an EHR go-live to child-birth; the hard work is just beginning. While you’re going to have frequent newsletters, emails and MEC presentations leading up to an EHR launch, don’t slow down. Gather feedback directly from users to determine key challenges and to prioritize change. Make it easy for clinicians to give feedback by connecting with them in the physician lounge or accompanying them on rounds. Do more than providing an issue or ticket tracking system – stay connected in their world, on the units, in the clinics. Your CMIO and CNIOs should be familiar faces at your sites bringing updates, feedback and asking for more. For those leaders who always wanted to be in a band and go on a road show, you’ve got your shot.

Many of us have a future vision of powerful data warehouses, predictive analytics, evidence-based practice driving improved financial and clinical performance with improved patient satisfaction and care. We’ve seen the bells and whistles of EHR systems, and we have IT teams eager and ready. Let’s show our users we’ve heard them – how can you improve your clinician adoption?

Jaffer Traish is director of Epic consulting at Culbert Healthcare Solutions.

News 10/31/13

CareCloud will integrate ZocDoc’s appointment booking app into its platform, allowing patients to book appointments online with CareCloud providers via ZocDoc.

WebMD jumps into the patient engagement space with the acquisition of Avado, a developer of patient relationship technologies. Avado offers an EMR-agnostic patient portal that includes messaging, reminders, and appointment scheduling tools.

Rush Health (IL) endorses the eClinicalWorks EHR solution for its 300 affiliated private physician members.

SuccessEHS will integrate the DataMotion Direct secure messaging service into its EHR platform.

Vitera announces the availability of Intergy Mobile 2.0 in the Apple Store.

Physicians continue to be uncertain about how the ACA rollout will impact their workloads or wallets, according to a USA Today news story.  Physicians point to the need for increased efficiencies and a shifting of non-clinical tasks to administrative staff.  AAFP president Reid Blackwelder, MD adds that medical teams need to learn how to “work smarter, not harder” and use electronic systems better.

I am looking for a few volunteers from HIT vendors to participate in a Q&A for HIStalk Practice. Specifically I would like a few sales types (or even former salespeople), as well as implementation and training experts that work with physician offices. I can’t guarantee that your few minutes of  time will result in fame and fortune, but be assured I would be very grateful. Email me for details.

As you get ready for your Halloween office party or a night of treat or tricking with the kids, here are a few Halloween health hazards you may want to avoid – unless you work in a hospital or practice with medical staff close by. Crazy-colored contact lens that may damage eyes are a top concern, as are skin-irritating makeup, pumpkin-carving injuries, and general candy overload. Personally I plan to play it safe and stick with my stand-by Wicked Witch costume and limit my evening intake to chocolate and a side of wine.

Send Inga treats or emails.

News 10/29/13

Athenahealth will implement Safety Event Manager, a safety reporting solution from Quantros, allowing athenaClinical users to submit patient safety data as part of their EHR workflow to the federally sanctioned Quantros Patient Safety Center

The Government Accountability Office reports that general practice physicians were 1.5 times more likely than specialty practice physicians to have been awarded a MU incentive payment in 2012. A total of 183,712 EPs were awarded payments in 2012, representing 31 percent of all EPs and an increase from the 53,331 (10 percent) of EPs awarded incentives in 2011; 75 percent of EPs awarded incentive payments in 2012 were new to the program.

Greenway Medical Technologies is named a finalist for the 2013 Intel Innovation Award in recognition of its PrimeMOBILE app for Windows 8.

A pediatric mental health study using athenahealth claims data reveals a 29 percent increase in the rate of mental health diagnoses between 2009 and 2013. ADHD accounted for more than half of all pediatric mental health diagnoses.

In 2011, office-based physicians using an EHR were more likely than non-EHR users to exchange lab results, send prescriptions electronically, and provide patients with clinical summaries, according to a study conducted by the CDC’s National Center for Health. Specific data exchange functions included:

• Viewing lab results online: 87 percent with EHRs vs. 67 percent of all physicians
• Sending prescriptions electronically: 78 percent vs. 55 percent
• Incorporating lab results into an EHR: 73 percent vs. 42 percent
• Providing patients with clinical summaries: 61 percent vs. 38 percent
• Sending lab orders electronically: 54 percent vs. 35 percent
• Exchanging clinical summaries with other providers: 49 percent vs. 31 percent.

Not surprisingly, data exchange capabilities varied significantly depending on the EHR: the ability of providers to exchange clinical summaries, for example, ranged from one-fourth of all physicians to three-fourths, depending on the EHR.

In an interview, eClinicalWorks CEO Girish Navani shares various observations and predictions for the industry. Some notable comments:

We are headed for consolidation, without a doubt. It’s not just going to be the smaller or the insignificant. I think you will find companies that have not built customer bases or are strongly relying on investors to fund their next generation of products having to either consolidate or merge. It happens in every industry, and it’s going to happen in our industry. I wouldn’t be surprised if you see some reasonably large businesses next year get acquired or merge with each other.

The right to earn a physician’s business is going to get harder, because you will be in what I would call a replacement market. You need to have a better product and a better service, and you need to be able to keep your customer base. I think size will matter, at some point, just like it did in the cell phone business. Verizon and AT&T built more connections, so they got more subscribers. I think you’ll see some of that, as well. I wouldn’t be surprised if a larger business that can’t invest in research and development, and can’t show the same top line growth will get pressured by stock prices or investors to merge with something else

I think in 2013 we are still amidst the transition where we now understand that our reimbursements will be tied to outcomes. I don’t think we have yet changed the consumers’ behavior around looking at those indicators in terms of how and where they derive their quality or care. But if you ask me, the question over the next 5 years, we’re definitely moving to consumer-centered care. The patients will make decisions based on price, quality, and also convenience in terms of how and where they get their care. Again, it will go faster than you and I expect. My gut tells me if we look back within 12, if not 18 months, we will be pleased that healthcare has moved past digitization of technology to using it as a vehicle for better decision making.

Email inga.

News 10/24/13

A Forbes article highlights Practice Fusion’s possible privacy problems stemming from  their practice of emailing patients to request physician reviews. This is a topic we mentioned a couple times on HIStalk Practice, including in this post by Dr. Gregg. The article criticizes Practice Fusion for possible HIPAA violations, drawing the above response from CEO Ryan Howard. While Howard contends the accusations are “false,” Forbes’ Kashmir Hill stands her ground and a few other readers pile criticisms on as well (check out the comments at the end of the article.) Practice Fusion has added a new blog post further clarifying their patient survey policy, but I doubt we’ve heard the end of this story.

Rush Health (IL) endorses athenahealth’s EHR and PM services for its 300 affiliated private physician members.

CMS publishes the 2013 Interim Feedback Dashboard User Guide to assist EPs with accessing and interpreting the status of PQRS data to monitor claims-based individual measures and measures group reporting.

The 150-provider Rothman Institute (PA) selects White Plume’s ePASS product suite to automate the charge capture process and prepare for ICD-10.

More than three-quarters of parents participating in a University of Michigan poll would likely seek email advice for their children’s minor illness if that service were available, though almost half feel the consult should be free. What’s unclear from the report is whether parents think physicians should not charge for this service, or, if they believe that insurance should pick up the tab for the consult. Regardless, we are clearly a society that believes we are entitled to many things.

The clever folks at NueMD produce a Miley Cyrus “Wrecking Ball” parody that satirizes how doctors at small medical practices are being knocked out by a “wrecking ball” masquerading as government regulation and payer obstacles. It might be funnier if it didn’t hit so close to home.

Email Inga.